County Acts to Stem More Trauma Unit Withdrawals

In an effort to halt further erosion of Los Angeles County’s troubled trauma center network, the Board of Supervisors on Tuesday ordered that hospitals with the largest caseloads of indigent patients be given first priority for transferring those patients to county hospitals.

The board action is intended to ease the financial burden on those hospitals with large numbers of non-paying, poor patients, but health officials expressed concern that such a move might backfire and actually create more money problems for some hospitals in the trauma network.

Under the current system, every private hospital that wants to transfer an indigent patient to a county facility is placed on a waiting list because unoccupied beds in county hospitals are scarce. Transfers are limited to patients who are in stable medical condition. Private hospitals seek to transfer non-paying patients because they otherwise have to absorb the cost of caring for them.

But the supervisors directed county Health Director Robert Gates to work with the Hospital Council of Southern California, which represents private hospitals, to identify those private hospitals with a “disproportionate” number of indigent patients and assign them transfer priority.

Opposite Effect

Although aimed at averting any further trauma network withdrawals, Gates said after the meeting that such a system might actually have the opposite effect in some cases. That is because the proposal would give a higher transfer priority to hospitals with large overall caseloads of indigent patients, regardless of whether they have a trauma center, he noted. For example, a hospital with a large number of indigent trauma patients, but a relatively small overall indigent caseload, might lose out to a hospital with a large percentage of indigent patients and no trauma center at all.

Gates said such inner-city hospitals as California Hospital Medical Center and Hollywood Presbyterian might benefit most by a new priority transfer plan, although they have dropped out of the trauma center network. That is because the two hospitals have a heavier percentage of indigent patients than a suburban hospital with a trauma center, such as Huntington Memorial in Pasadena.

The board-ordered transfer priority plan makes no distinction between hospitals with a trauma center and those without one, Gates said.

The board acted on proposals drawn up as a result of the announcement by Daniel Freeman Memorial Hospital in Inglewood that it was withdrawing from the county’s trauma network. The withdrawal was effective Monday. Daniel Freeman officials cited millions of dollars in losses that they blamed on a large number of indigent trauma patients.

The hospital is the fourth to abandon the 3-year-old trauma system and the second this year. Earlier, two other busy trauma hospitals, Hollywood Presbyterian and California, pulled out for financial reasons, as did smaller Pomona Valley Community Hospital.

Private hospital officials have said that the difficulty in transferring indigent patients to the county is a significant factor in driving up trauma care costs.

Trauma care is expensive, and because the indigent patients--essentially the working poor who do not qualify for Medi-Cal--do not have health insurance, the private hospitals often wind up providing treatment without much chance of reimbursement.

Daniel Freeman’s withdrawal was also significant because for the first time, residents of one area of the county are not within a 20-minute ambulance ride of a trauma center. More than 400,000 people once within Daniel Freeman’s designated trauma area will instead now be taken to the nearest emergency room, which may not be equipped with all of the sophisticated equipment or specialized medical personnel required in the county’s major trauma centers.

The remaining 19 private trauma hospitals have urged a preferential transfer system for indigent trauma patients since Daniel Freeman’s initial pullout announcement. But other non-trauma hospitals hard-hit by indigent patient loads insisted that any transfer priority plan must consider the entire scope of medical treatment, not just trauma care.

Few Details

Neither Gates nor Kathleen Belkham, the Hospital Council’s regional director, could offer many details of what the new transfer system would include. They also have not arrived at a definition of what constitutes a “disproportionate” load of indigent patients that would determine which private hospitals would have first crack at a vacant county hospital bed.

Belkham said those hospitals most likely to be first in line for county beds are those with more than half of their patient care dollars going to indigent patients.

“Most hospitals can afford a 5% uncompensated load and do just fine,” she said.

In other action, the board agreed to maintain, for the time being, a requirement that each trauma center have an anesthesiologist on duty 24 hours a day. Paula Woo, chairwoman of the county’s Emergency Medical Services Commission, told the board that not enough data exists to relax the anesthesiologist standard. Many of the trauma hospitals have argued that the requirement is too expensive and that the anesthesiologist should be on call.

Data Program

The board also froze for at least a year the $15,000 fee the county was charging the trauma hospitals to participate in a data-gathering program. Gates, who had sought a $10,000 increase in the annual fee, called the board vote a “symbolic gesture” because none of the hospitals had threatened to withdraw from the network if the increase had been imposed.

When the county trauma center network was established in 1983, after years of contentious planning, it was cited as a model for other communities in the nation. At the time, hospitals competed to participate in what they regarded as a prestigious program. While no more hospitals have threatened to immediately withdraw from the system, the costs associated with it have sparked a re-examination.